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MPFL reconstruction

171 citationsUpdated Oct 2026

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Overview

Medial patellofemoral ligament (MPFL) reconstruction is a durable surgical treatment for patients presenting with either first-time or recurrent patellar instability, characterized by relatively low rates of recurrent instability and failure [42]. The procedure may serve as a more durable option with lower rates of recurrent instability and failure when compared with other patellofemoral stabilization procedures at up to 10 years after surgery [76]. Midterm outcomes for isolated MPFL reconstruction are favorable and remain maintained at 5 years [9], with functional outcomes remaining favorable as complication and failure profiles improve with widespread implementation [78]. In challenging cohorts with multiple severe anatomical risk factors, including severe trochlear dysplasia, increased tibial tuberosity–trochlear groove distance, patella alta, and lower extremity torsion deformities, isolated MPFL reconstruction achieves good short-term clinical results [2]. In this specific population, 93% of patients returned to sports, while the redislocation rate was 7.4% [2].

The procedure is indicated for a broad range of patient demographics and anatomical presentations. MPFL reconstruction using allograft tissue may be performed safely in the pediatric and adolescent population, yielding good outcomes at mid-term follow-up with few complications and a low rate of recurrent instability [29, 60]. For young adults, combined MPFL and medial patellotibial ligament (MPTL) reconstruction results in significant improvement in subjective knee function with minimal risks, although preinjury activity levels are not consistently restored [4]. The addition of an appropriately indicated tibial tubercle osteotomy to MPFL reconstruction appears to be both safe and effective [39], and outcomes and risk profiles for MPFL reconstruction with concomitant tibial tubercle transfer are similar to those of isolated MPFL reconstruction [8]. An increase in previously reported thresholds for when to add a bony procedure to an MPFL reconstruction can result in successful outcomes in some patients [77].

Graft selection and fixation techniques offer multiple viable options with comparable efficacy. Both allograft and autograft remain viable options for MPFL reconstruction, with no significant differences in failure rates, patient-reported outcomes, pain, or complications [24, 30]. Allografts may represent a feasible alternative to traditional autograft for MPFL reconstruction in selected patients with patellofemoral instability [71]. MPFL reconstruction with both semitendinosus and pedicled quadriceps tendon grafts yields successful results in well-selected patient groups [211]. Regarding fixation, both suture anchor and interference screw techniques for patellar fixation provide greater ultimate failure loads than those reported for the native MPFL in previous studies [27]. Both open and radiographic localization of the femoral graft position offer similar outcomes and rates of complications [3]. Various techniques, including the "double-socket" technique and a divergent patellar transverse 2-tunnel technique, are simple, anatomic, cost-effective, and provide comparable early and medium-term results to other reported methods [47, 33]. MPFL repair and reconstruction provide similar clinical results, return to play rates, and reoperation rates [6], though MPFL reconstruction may provide improved midterm clinical outcomes and a decreased recurrence rate compared with MPFL repair [10]. MPFL reconstruction surgery combined with lateral retinacular release failed to demonstrate significantly different functional outcome scores and failure rates compared with isolated MPFL reconstruction at minimum 1-year follow up [5]. Both MPFL reconstruction and tibial tubercle transfer procedures are viable procedures allowing quick recovery, low rates of instability, and minimal risk of complication [28]. Further investigation is needed to determine safe and effective guidelines for return to play after MPFL reconstruction and repair [1].

Anatomy & Pathophysiology

Medial Patellofemoral Complex Anatomy

The medial patellofemoral complex (MPFC) comprises fibers attaching to the patella, specifically the medial patellofemoral ligament (MPFL), and the quadriceps tendon, identified as the medial quadriceps tendon femoral ligament (MQTFL) [238]. The midpoint of the MPFC is consistently located at the junction of the medial quadriceps tendon with the articular surface of the patella [238]. The MPFL functions as a reinforcing band extending from the patella, serving as a more critical structure for patellar stability than other medial capsular components [88]. It runs from the patella near the junction of the middle and superior thirds to the medial femoral epicondyle [88]. The medial capsule is more distinct and well-defined than its lateral counterpart, with the anteromedial portion being a relatively thin structure reinforced by medial patellar retinacular expansions [88]. Both the MPFL and the medial patellotibial ligament act as reinforcing bands extending from the patella to support patellar tracking [88].

Cadaveric data indicate that attachment sites of proximal quadriceps fibers vary considerably, with some attaching exclusively to the patella and others solely to the quadriceps tendon [35]. Inferior-straight fibers of the medial restraints insert on the patella, while superior-oblique fibers attach to the quadriceps tendon [35]. Anisometry exists between the bundles of the medial restraints throughout knee motion [35]. The medial knee is organized into three layers: Layer I (deep fascia), Layer II (superficial MCL, tendons, posterior oblique ligament), and Layer III (joint capsule, deep MCL, coronary ligaments) [99]. The medial epicondyle represents the most anterior and distal osseous prominence of the medial femoral condyle, while the adductor tubercle is located proximal and posterior to the medial epicondyle [85].

Patellar and Femoral Anatomy

The patella is the largest sesamoid bone in the body, averaging 2.5 cm in thickness [85, 99]. It possesses the thickest articular surface in the body, measuring approximately 5 mm in the midportion and 2 mm on the sides [85]. The patellar articular surface contains a vertical central ridge separating the broader lateral facet from the medial facet, plus a smaller medial odd facet [85]. The odd facet is a small facet on the distal medial patella that articulates in deep flexion of the knee [99]. The lateral trochlear facet resists lateral subluxation of the patella [99].

The medial femoral condyle is larger and projects farther posteriorly and distally than the lateral condyle [85]. Conversely, the lateral femoral condyle projects farther anteriorly and is wider in the medial-lateral direction than the medial condyle [85]. The sulcus terminalis is a transverse ridge extending from the oblique facets of the femoral trochlea, deeper on the lateral condyle than on the medial condyle [99].

Biomechanics and Kinematics

The patella aids in knee extension by increasing the lever arm and distributing stress [100, 101]. It bears half the body weight with normal walking [100, 101] and seven times the body weight with squatting and jogging [100, 101]. Patellofemoral loads are proportional to the ratio of quadriceps force to knee flexion [100, 101]. In descending stairs, compressive force on the patellofemoral joint reaches two to three times body weight [100, 101]. The quadriceps produces maximum anterior force on the tibia at 0 to 60 degrees of knee flexion [100, 101].

Anatomically positioned MPFL reconstruction with 2-N tension fixed at 30° or 60° of knee flexion restored joint contact pressures and tracking [123]. A pretension of 2 N was found to restore the knee joint closest to normal patellofemoral kinematics [131]. MPFL grafts tend to carry minimal load beyond 30 degrees of knee flexion during functional activities [193]. Anatomic MPFL reconstruction resulted in a favorable graft length change range of less than 2 mm at 0 to 90 degrees of knee flexion, close to isometric behavior [161]. Kinematics were not optimal with the use of a smaller tubular graft compared to the native fan-shaped MPFL [147]. Patellar contact pressures after dynamic MPFL reconstruction were similar to those of the native knee, whereas static reconstruction resulted in greater pressures [183]. Anatomic reconstruction of the MPFL may not fully restore patellofemoral pressure distributions compared to the native knee [162].

MPFL reconstruction restores patellar kinematics and contact mechanics to the intact state when the tibial tubercle is in an anatomic or 5-mm lateralized position, but fails to do so when lateralized by 10 mm or 15 mm [154]. In knees with patella alta (IS 1.5), a slightly more proximal femoral insertion is beneficial for the biomechanical behavior of the reconstructed MPFL [70]. The MPFC fibers demonstrated increased length changes in knees with a greater number of morphological risk factors for patellar instability, which worsened in the setting of nonanatomic configurations [203]. Abnormal MPFL kinematics may cause overconstraint and increased cartilage pressures of the medial patellofemoral joint [153]. Radiographic measures of tracking and alignment changed with knee motion and were most abnormal at lower flexion angles in knees with instability symptoms [138].

Injury Pathophysiology

The understanding of the complexity of the medial patellar stabilizers continues to evolve [31]. Recognition of evolving medial patellofemoral anatomy has led to paradigm shifts in reconstructive approaches [35]. Restoring the MPFC, rather than a single ligament, provides a more accurate reproduction of native biomechanics [35]. Combined MPFL and MQTFL reconstruction respects the layered anatomy of the medial restraints and more closely replicates physiologic restraint across the range of knee motion [35]. The altered function of the patellar tendon in anterior cruciate ligament deficiency resulted in altered patellar tracking and patellofemoral cartilage contact [184]. Medial patellar instability following lateral retinacular release occurs during the unloading phase of gait when passive structures guide the patella [194]. Distinct anatomical phenotypes underlie dynamic patellar maltracking [149].

Classification

Dejour and Le Coultre: This classification system defines trochlear dysplasia severity as no dysplasia, low-grade dysplasia (Type A), or high-grade dysplasia (Types B, C, and D) based on true lateral radiographs and axial MRI scans [53]. The system is also depicted on axial MRI scans as normal trochlea, Dejour A (shallow >145° trochlea), Dejour B (flat trochlea), Dejour C (dominant and convex lateral trochlear facet), and Dejour D (absence of a medial trochlear facet) [230].

Type A: Characterized by a visible crossing sign on lateral radiographs and a symmetric but shallower trochlear groove with a sulcus angle greater than 145° on axial images [53].

Type B: Entails a crossing sign and a supratrochlear spur on lateral radiographs, with a flat trochlea on axial images [53].

Type C: Involves a crossing sign and double contour on lateral radiographs, with lateral facet convexity and medial facet hypoplasia on axial images [53].

Type D: Involves a crossing sign, supratrochlear spur, and double contour on lateral radiographs, with a "cliff" on axial images due to asymmetry of the lateral and medial femoral trochlear facets [53].

Clinical Presentation

Preoperative Assessment and Indications

MPFL reconstruction is indicated when there is loss of the medial retinacular patella stabilizer due to recurrent lateral patella dislocations [141]. Indications require documented MPFL laxity via physical exam, stress radiographs, or arthrometrer testing [141]. The procedure is not indicated for isolated patellofemoral pain, excessive patellofemoral lateral tilt or translation without instability, or patellofemoral arthritis [141]. An exam under anesthesia and arthroscopy can document MPFL laxity without guarding or apprehension [141]. Arthroscopy is most helpful to stage cartilage lesions during preoperative evaluation [141]. It typically shows excessive lateral tilt and translation through a passive range of motion due to medial retinacular laxity with the joint distended [141]. However, lateral maltracking cannot be judged based on the arthroscopic view of excessive lateral tilt and translation [141]. If bony malalignment, trochlear dysplasia, or patella alta is identified during the preoperative workup, an isolated MPFL reconstruction must not be performed [121].

A preoperative jumping sign was present in almost 70% of patients with MPFL graft failure [46]. Diagnostic arthroscopy with MPFL reconstruction may result in findings not previously appreciated on MRI [45]. Respondents to an international survey considered age, generalised joint laxity, positivity/negativity of clinical tests of instability, contact sports participation, and associated medial patellofemoral ligament lesions as possible indications for direct surgical management of the first episode of traumatic patellar dislocation [137]. Sex and affected side were not relevant in the surgical algorithms for managing the first episode of traumatic patellar dislocation according to an international survey [137].

Intra-articular Pathology

Substantial cartilage injuries are present in 56% of patients who undergo primary isolated MPFL reconstruction [55]. Medial patellar lesions are the most common type of cartilage injury in patients undergoing primary isolated MPFL reconstruction [55]. Substantial cartilage damage was present in 56% of patients who underwent isolated MPFL reconstruction for recurrent patellar instability [62]. Medial patellar lesions are the most common type of cartilage damage in patients undergoing isolated MPFL reconstruction for recurrent patellar instability [62]. Increased age at surgery is associated with an increased risk of substantial cartilage damage in patients undergoing MPFL reconstruction [136].

Outcomes and Return to Sport

Isolated MPFL reconstruction allowed return to pre-injury sports in 91% of patients [16]. 67% of patients returned to the same or higher level than pre-injury after isolated MPFL reconstruction [16]. Surgical stabilization including MPFL reconstruction is an effective procedure for returning athletes to competitive sports with good clinical outcomes and a low rate of recurrence at 4-year follow-up [11]. Clinical scores after MPFL reconstruction provide only little insight into return to sport [7]. Patients that do not return to play following MPFL reconstruction exhibit poor psychological readiness [20]. The most common reason for patients not returning to play following MPFL reconstruction is fear of re-injury [20]. Adolescent patients with MPFL reconstruction exhibited altered squat and jumping mechanics during the return to sport phase [54]. Patients who underwent isolated MPFL reconstruction reported significantly higher rates of return to the same or higher level of sport compared to those who underwent combined MPFL reconstruction and tibial tubercle osteotomy [50]. Patients undergoing MPFL reconstruction with or without correction of bony malalignment reported significant improvement over time with high return to sport rates and low recurrent dislocation rates [21].

Complications and Failure Rates

Complications following primary MPFL reconstruction ranged from 0% to 32.3% of knees [18]. Residual anterior knee pain was the primary complication following primary MPFL reconstruction [18]. The redislocation rate after isolated MPFL reconstruction in a cohort with multiple severe anatomical risk factors was 7.4% [2]. 93% of patients returned to sports after isolated MPFL reconstruction in a cohort with multiple severe anatomical risk factors [2]. MPFL reconstruction in isolation or combined with MPTL reconstruction in skeletally immature patients with additional uncorrected anatomical patellofemoral abnormalities has a high failure rate of 24.1% [56].

Investigations

MRI: Magnetic resonance imaging accurately diagnoses femoral MPFL injury in patients presenting with first-time patellar dislocations, a diagnostic capability that arthroscopy does not possess [34]. When a primary MPFL repair is planned, the determination of the repair site must be based on the preoperative MRI findings [34].

Plain radiography: Measurement of the femoral tunnel position on postoperative lateral radiographs is not an accurate or reliable method for evaluating tunnel position after MPFL reconstruction. This limitation arises from exposure, contrast, and malrotation of the radiograph relative to a true-lateral image [214].

CT: Patients who underwent an MPFL reconstruction in addition to a tibial tubercle transfer (TTT) demonstrated comparatively significant improved patella congruence on quantitative CT scan [41].

Other Considerations: Substantial cartilage injuries are present in 56% of patients who undergo primary isolated MPFL reconstruction, with medial patellar lesions being the most common [55]. Similarly, substantial cartilage damage was present in 56% of patients who underwent isolated MPFL reconstruction for recurrent patellar instability, with medial patellar lesions being the most common [62]. No anatomic risk factor independently influenced the clinical results after MPFL reconstruction significantly [23].

Postoperative Radiographic Outcomes: MPFL reconstruction provides a consistent reduction in patellar height measurements [228]. However, reconstruction of the MPFL produced no improvement in patellar tilt or shift in the population studied [72].

Treatment

Non-Operative

MPFL reconstruction is indicated for patients with recurrent patellar instability who have failed nonoperative management [66].

Operative

Indications: MPFL reconstruction restores static medial stabilization in patients with recurrent patellar instability [66]. Joint hypermobility is not a contraindication, though caution is recommended when managing expectations for hypermobile patients prior to surgery [186]. Clinical success depends on restoring the anatomical origin of the MPFL and careful patient selection [245]. Patients aged ≥30 years at the time of reconstruction demonstrate similar subsequent dislocation risk but poorer KOOS pain subscale and Marx activity values compared with patients <30 years [80]. In skeletally immature patients with first-time patellofemoral dislocation, MPFL/MQTFL reconstruction demonstrated lower failure rates and improved functional outcomes at a minimum 2-year follow-up compared with nonoperative management [15].

Surgical Approach / Technique: The standard approach involves a mini-open incision at the patellar insertion and femoral origin, with arthroscopic extraarticular reconstruction offering advantages of an individualized, minimally invasive, and cosmetically appealing procedure [231]. Accurate localization of the anatomical insertion site is critical for success, and many authors recommend intraoperative fluoroscopic guidance for positioning [250]. The anatomical insertion is inferred to be the isometric point at the femoral attachment [239]. Clinically, reconstruction should fix the anterior end to the VMO rather than the patella [63]. Fixation of the MPFL graft at 60° of flexion most closely restores patellofemoral contact pressure compared with the intact knee [67]. A tailored surgical treatment addresses the specific pathologic anatomy predisposing to lateral patellar dislocation, performing MPFL reconstruction in every patient while applying other techniques in individual combinations dependent on patient needs [242]. Recognition of evolving medial patellofemoral anatomy has led to paradigm shifts emphasizing that restoring the MPFC (MPFL and MQTFL) rather than a single ligament provides a more accurate reproduction of native biomechanics [35]. The combined MPFL and MQTFL approach allows for a more anatomic reconstruction of medial knee structures than previous approaches [51]. Medial quadriceps tendon femoral ligament reconstruction is the most anatomic repair, resulting in less overconstraint compared to MPFL reconstruction, though differences are small and surgical technique details remain critical [130]. MQTFL is a biomechanically robust alternative to MPFL reconstruction, potentially reducing fixation-related complications [174].

Graft Selection: The most typical grafts used for MPFL reconstruction are hamstrings, allografts, and synthetic grafts [79]. In adolescent patients, there were no significant differences in return to activity, pain score changes, or incidences of failure between patients undergoing MPFLR with allograft versus autograft [221]. MPFL reconstruction using superficial quadriceps tendon autograft can be performed with a minimally invasive technique without specialized instrumentation and has shown excellent knee functional improvement [126]. A technique for reconstruction of the MPFL and MPTL can be performed through a minimally invasive approach and has been shown to be successful in restoring stability in patients with traumatic and recurrent patellar instability [118]. A mini-invasive method using adductor magnus tendon transfer is a relatively easy procedure that provides graft strength comparable to previous techniques [127]. An anatomical MPFL reconstruction using a free gracilis autograft enables the reconstructed ligament to have an isometric function, be effective through a greater range of motion, enable early functional rehabilitation, and avoid an increase of patellofemoral pressure in higher degrees of knee flexion [32]. The same paediatric MPFL reconstruction technique (Chassaing) uses a gracilis tendon graft passed through the middle layer of the patellar retinaculum and fixed through a patellar tunnel, providing favourable graft anisometry characteristics [243].

Fixation Techniques: MPFL-R with soft-tissue graft fixation at the femoral condyles resulted in subjective clinical outcome, patellar stability, and pain level findings similar to those associated with MPFL-R with bone fixation [12]. MPFL reconstruction techniques with patellar bone sockets showed a larger range of complication rates than cortical fixation techniques, although overall complications remained uncommon [209]. MPFL reconstruction with 3 transosseous sutures provided a higher load to failure than the commonly used fixation method involving suture anchors [195]. Both reconstruction techniques (suture anchor vs. interference screw) provide greater ultimate failure loads than those reported for the native MPFL in previous studies [27]. The mean load-to-failure values for both reconstruction techniques (interference screw vs. suture anchors) were greater than the literature-reported values for the native MPFL [68]. Both fixation techniques (soft-tissue vs. suture-anchor) provided sufficient primary stability, superior to previously reported native MPFL tensile strengths [197]. Three methods of reconstruction were stronger than the native MPFL, with the strongest being interference screw patella suspensory cortical fixation femur [192]. There was no consensus on the use of anchors in MPFL reconstruction, the order of fixation of the graft, indications for trochleoplasty, postoperative immobilization, or early return to sport in paediatric patients [208].

Adjunctive Procedures: MPFL reconstruction surgery combined with LRR failed to demonstrate significantly different functional outcome scores and failure rates compared with isolated MPFL reconstruction at minimum 1-year follow up [5]. There is no indication for a systematic lateral retinacular release in association with MPFL reconstruction in the treatment of RPD [173]. In a cohort of patients undergoing MPFL reconstruction, the addition of an appropriately indicated TTO appears to be both safe and effective [39]. Matched patients undergoing MPFLR with TTO compared with isolated MPFLR demonstrate no statistically significant difference in patient-reported outcomes, levels of pain, and satisfaction postoperatively [254]. There was insufficient evidence to conclude that the addition of MPFL reconstruction to TTT results in fewer redislocations or reoperations [205]. Concomitant cartilage restoration does not demonstrate consistent additional clinical benefit in medial patellofemoral ligament reconstruction [40]. Combined MPFL and MPTL reconstruction in young adults results in significant improvement in subjective knee function with minimal risks, although preinjury activity levels are not consistently restored [4]. IMGG with plates or screws in the setting of combined MPFL reconstruction improves genu valgum in skeletally immature patients [188].

Pediatric and Skeletally Immature Patients: MPFL reconstruction in young patients can be considered an effective and safe treatment leading to clinical improvement in terms of recurrence of dislocation [17]. There are clinically relevant improvements in knee function and pain after MPFL reconstruction in paediatric patients [61]. This technique (physeal-sparing MPFL reconstruction with suture anchor) is technically simple and can be easily learned by surgeons familiar with adult MPFL reconstruction techniques [113].

Revision Surgery: Revision surgery for MPFLR failure, including the correction of major anatomic risk factors, yielded a significant improvement in patient-reported quality-of-life outcome measures [19]. MPFL reconstruction, alone or in combination, seems to be an effective treatment for recurrent patellar dislocations after a failed previous surgery, leading to significant increases in stability and functionality as well as a reduction in pain [227]. Femoral tunnel malposition is the most common indication for revision medial patellofemoral ligament reconstruction with promising early outcomes following revision reconstruction [253].

Outcomes and Complications: Complications following primary MPFL reconstruction ranged from 0% to 32.3% of knees, primarily consisting of residual anterior knee pain [18]. MPFL reconstruction decreases recurrent dislocation compared with MPFL repair or nonoperative treatment, but it has a higher possibility of complications [73]. PPR has demonstrated durable results, with a lower overall complication rate, much of which is caused by the MPFL reconstruction having unique complications due to fixation methods [204]. The lower incidence of pain complaints in the MPFL reconstruction group encourages its use as the first choice technique compared to other stabilization methods [69]. These results suggest that pediatric opioid prescribing practices after MPFLR have become more conservative, reflecting ongoing efforts to reduce opioid use in surgical care while maintaining effective pain management [215].

Biomechanics and Technical Considerations: The described MPFL reconstruction technique using a looped, double-bundle graft replicates the native shape of the MPFL while effectively limiting rotation throughout ROM and minimizing postoperative instability [48]. Double-bundle artificial MPFL reconstruction using a femoral suture-sliding anchor and staged patellar fixation offers a reproducible method to adjust graft tension, reduce the risk of over-constraint, and better restore the anatomical configuration of the native MPFL [181]. MPFL-R with a nonresorbable suture tape can normalize patellar maltracking in fresh-frozen human knee joint specimens in earlier degrees of knee joint flexion independent of patella-side fixation technique [219]. These early and medium-term results (divergent patellar transverse 2-tunnel technique) are comparable with those of other MPFL reconstruction techniques reported in the literature [33]. Our technique (double-socket) is simple, anatomic, and cost-effective in incorporating the advantages of various techniques to provide a strong MPFL reconstruction with minimal complications [47]. It (double adjustable-loop cortical buttons) represents an alternative to traditional anchor- or screw-based MPFL reconstruction methods [57]. They consider the introduction of this technique (wide patellar insertion with internal bracing) will provide more insight to MPFL reconstruction [52]. The technique described (minimally invasive with patellar-sided tensioning using all-suture anchors) allows the surgeon to finely calibrate the amount of tension by passing sutures into the graft at the desired level, allowing both limbs of the graft to be tensioned independently and adjusted on the basis of patellar tracking and lateral translation [84]. The authors describe a technique for performing final graft tensioning from the patellar side during medial patellofemoral ligament (MPFL) reconstruction [124]. The authors describe a surgical technique for MPFL reconstruction using a suspensory fixation device for stable patellar fixation [125]. This technique (arthroscopic repair of acute traumatic MPFL tears at the patellar insertion) is a less invasive, straightforward, and reproducible method for repairing the torn MPFL [117]. This technique (allograft MPFL reconstruction using patellar suture anchors and stepwise medial imbrication) provides a thoughtful and durable method for MPFL reconstruction and may be performed as an isolated procedure or in conjunction with adjunctive bony or cartilage procedures [120]. MPFL reconstruction with a free semitendinosus graft using a suspensory adjustable-loop cortical button and interference screw fixation on the femoral side, as well as knotless suture anchor fixation in 2 bone sockets on the patellar side, is a reproducible technique for patellar stabilization in patients with acute or recurrent instability [196]. The surgical technique (quadriceps tendon graft) consisted of 10 steps, including arthroscopic examination, graft harvest from the superficial slip of the quadriceps tendon, and preparation for repositioning [201]. The MPFL reconstruction was performed using two separate incisions at the medial side of patella and at the femoral insertion of the MCL, with double-strand semitendinosus tendon or gracilis tendon used as a graft tissue [252]. The surgical technique (VMO advancement and native MPFL imbrication) involves sharply incising a sleeve of retinaculum over the dorsal patella to retrieve tagged sutures of the VMO and native MPFL, advancing them, and securing them to the dorsal patellar retinaculum with nonabsorbable suture in a figure of 8 interrupted fashion [241]. The MPFL was torn near two 3-cm incisions at the medial border of the patella and distal femur slightly distal to the adductor tubercle in the biomechanical comparison study [249].

Complications

Instability: Recurrent patellofemoral instability remains a significant concern, with an overall risk of recurrent dislocation reported at 21% despite the rapid increase in procedures from 2005 to 2013 [81, 82]. However, recurrence rates vary widely depending on graft choice and study duration; published studies report a recurrence rate of 0% to 4%, though follow-up in these studies was short [212]. The use of either allograft or autograft tissue results in a very low (<3%) risk of repeat dislocation [226], and recurrent patellofemoral instability rates after MPFL reconstruction techniques are comparable to instability rates after other soft tissue realignment techniques [272]. In a cohort of 179 knees in young patients, 29 knees (16.2%) had an identifiable complication [142], of which 34 were considered major and 4 were minor [142].

Stiffness / Arthrofibrosis: Flexion contracture due to excessive graft tension is the most common complication of MPFL reconstruction [212]. Joint stiffness was the most common complication reported in a series of 320 knees undergoing MPFL reconstruction [240]. Major complications described in a series of 620 MPFL reconstructions included revision operations due to loss of flexion [240].

Patellar / Extensor-mechanism: Patellar fractures occurred in 10 (1.1%) of 930 patients in a reported series of MPFL reconstructions [240]. In a study comparing pedicled quadriceps tendon autograft to gracilis tendon autograft, patellar fracture or any other major complication requiring surgical revision occurred in neither group [240]. Malpositioning of the femoral tunnel (38.2%), unaddressed trochlear dysplasia (18.4%), and patellar fractures (11.8%) are the most common causes for revision operation after MPFL reconstruction [240]. Multiple anatomic risk factors and femoral tunnel malposition are commonly observed in patients with reinstability after primary MPFL reconstruction [266].

Other Considerations: Functional failures after MPFL reconstruction combined with bony procedures ranged from 0% to 8.8% [114], while minor complications ranged from 0% to 40% [114]. Reoperations after MPFL reconstruction combined with bony procedures ranged from 4.5% to 17.65% [114]. A meta-analysis of 17 case series shows that MPFL reconstruction for recurrent patellar dislocation results in an acceptable complication rate [275], and widespread implementation of MPFL reconstruction maintains functional outcomes while decreasing complication rates [78].

Patients with suture anchor fixation at the patella site reported significantly less-positive apprehension tests, revision surgeries, and anterior knee pain compared with bone tunnel and interference screw fixation [240]. The lower incidence of pain complaints in the MPFL reconstruction group encourages its use as the first choice technique compared to repair [69]. Conversely, MPFL primary repair had a significantly increased rate of complication requiring re-operation, particularly recurrent patella instability requiring revision to MPFL reconstruction, in patients under 18 years old [83]. The surgical procedure of operative repair (reattachment) of the MPFL to its femoral attachment had a significantly high rate of failure in patients with chronic (repeat) lateral patellar dislocations [265].

Regarding graft and fixation specifics, patients treated with MPFL reconstruction experienced similar complication profiles irrespective of whether autograft or allograft was used [74, 75]. MPFL reconstruction using allograft tissue may be performed safely in the pediatric and adolescent population with few complications and a low rate of recurrent instability [29], and there was a low complication rate following MPFL reconstruction with allograft [260]. Significantly more patients treated with gracilis tendon reported a sensory loss in the lower leg compared with those treated with quadriceps tendon [240]. MPFL reconstruction with soft-tissue graft fixation at the femoral condyles resulted in findings for subjective clinical outcome, patellar stability, and pain level similar to those associated with MPFL reconstruction with bone fixation [12].

The addition of tibial tubercle osteotomy (TTO) to MPFL reconstruction increased the overall complication rate but had a lower 2-year rate of recurrent instability requiring revision than MPFL reconstruction alone [257]. The addition of TTO to MPFL reconstruction reduced revision surgical rates for instability from 11.1% to 6.6%, though this difference was not statistically significant [276]. MPFL reconstruction combined with lateral retinacular release failed to demonstrate significantly different functional outcome scores and failure rates compared with isolated MPFL reconstruction at minimum 1-year follow-up [5]. Approximately 23% of primary MPFL reconstruction patients underwent concomitant lateral retinacular release or lengthening [267, 271].

Revision surgery for failed MPFL reconstruction, including the correction of major anatomic risk factors, yielded a significant improvement in patient-reported quality-of-life outcome measures [19]. Although revision MPFL reconstruction establishes acceptable patellar stability, the subjective outcomes after revision do not improve significantly and are poorer than after primary MPFL reconstruction [274]. Tailored revision surgery for failed MPFL reconstruction significantly improves the patient-reported disease-specific quality of life when performed for recurrent instability [259]. Primary MPFL reconstruction with concomitant tibial tubercle osteotomy versus revision MPFL reconstruction with concomitant tibial tubercle osteotomy have comparable objective and subjective outcomes at short-term follow-up [261, 262]. Surgical stabilization including MPFL reconstruction is an effective procedure for returning athletes to competitive sports with a low rate of recurrence at 4-year follow-up [11].

Recovery

Light activity (weeks): The provided evidence does not specify a typical week range for light activities such as desk work, driving, or light activities of daily living.

Full activity (months): The evidence does not define a specific month range for the return to manual work or full range of motion and strength. However, young patients who return to sports at their pre-injury levels before 9 months after MPFL reconstruction experience a higher incidence of postoperative anterior knee pain and poorer functional outcomes compared to those who delay their return [155].

Complete recovery / outcome plateau (months): The evidence does not specify a month range for when pain, strength, and final functional outcomes stabilise.

Rehabilitation protocol: There is substantial variability in content and timing across rehabilitation protocols following MPFL reconstruction [139]. An accelerated rehabilitation program following isolated MPFL reconstruction is safe, effective, and yields a low risk of repeat dislocation [165]. Specifically, the risk of repeat dislocation with an accelerated rehabilitation program is less than 2% [180] and comparable to the risk reported in existing literature [180]. The technique of anatomical MPFL reconstruction using a free gracilis autograft enables an early functional rehabilitation [32]. Successful execution of MPFL reconstruction with lateral retinacular lengthening allows patients to undergo early aggressive rehabilitation and return to activities [182]. Clinicians should ensure that athletes are fully rehabilitated before returning to sport after MPFL reconstruction by emphasizing functional multijoint exercises [167].

Functional milestones: Patients with MPFL reconstruction experience worse persistent patient-reported and functional deficits during the terminal phases of rehabilitation as compared to individuals with ACL reconstruction [146]. The vastus medialis obliquus demonstrated a significant difference in activity between limbs at return-to-sport clearance following MPFL reconstruction [166]. This difference in vastus medialis obliquus activity at return-to-sport clearance suggests that there may be muscle weakness following surgery and ongoing through physical therapy [166].

Other Considerations: Return to Sport Rates and Levels: 67% of patients returned to the same or higher level than pre-injury following isolated MPFL reconstruction [16]. In a cohort with multiple severe anatomical risk factors, 93% of patients returned to sports following isolated MPFL reconstruction [2]. Patients undergoing isolated MPFL reconstruction reported significantly higher rates of return to the same or higher level of sport compared to those undergoing combined MPFL reconstruction and tibial tubercle osteotomy [50]. Conversely, 42% of patients return to sport at lower activity levels compared to pre-injury level following MPFL reconstruction [232]. Patients who undergo bilateral MPFL reconstruction return to sports at a similar rate and level compared to a unilateral comparison group [156] and report equivalent satisfaction and functional outcome scores compared to a matched unilateral comparison group [178]. Among US military servicemembers undergoing primary MPFL reconstruction, only 42.4% were able to return to unrestricted impact activity after surgery [148], while another cohort reported that only 50% of military servicemembers undergoing primary MPFL reconstruction were able to return to unrestricted impact activity [159]. Patients who underwent MPFL reconstruction with anteromedializing tibial tubercle osteotomy demonstrated similar rates of return to sport compared to an isolated MPFL reconstruction matched comparison group [206]. However, isolated MPFL reconstruction patients returned to sport more quickly than those who underwent combined MPFL reconstruction and tibial tubercle osteotomy [206].

Psychological Factors: The most common reason for poor psychological readiness in patients who do not return to play following MPFL reconstruction is fear of re-injury [20]. Individual psychological characteristics and personality structures have a significant influence on the functional outcome and the psychological readiness to return to sport after MPFL reconstruction [216]. Patients who underwent MPFL reconstruction with tibial tubercle osteotomy demonstrated similar psychological readiness compared to an isolated MPFL reconstruction matched comparison group [206].

Long-term Outcomes and Durability: Isolated MPFL reconstruction using a high-strength suture tape construct resulted in durable patellar stability and high patient-reported success at a minimum 5-year follow-up [268]. MPFL reconstruction remains as a durable surgical treatment option for patients presenting with either first-time or recurrent patellar instability with relatively low rates of recurrent instability [42]. The primary indicators of patient satisfaction at one year following MPFL reconstruction are young age, normal patellar cartilage, and good physical function at the time of surgery [163].

Key Evidence

• [L4] Further investigation is needed to determine safe and effective guidelines for return to play after MPFL reconstruction and repair. [1] (10.1177/0363546517713663)
• [L4] This study demonstrated that isolated MPFL reconstruction can achieve good short-term clinical results in a challenging cohort with multiple severe anatomical risk factors. 93% of patients returned to sports, and the 7.4% redislocation rate is comparable to rates reported in literatures and is acceptable given the high-risk profile. [2] (10.1186/s12891-026-09910-x)
• [L1] Both open and radiographic localization of the femoral graft position in MPFL reconstruction offer similar outcomes and rates of complications. [3] (10.1177/23259671221148482)
• [L4] Combined MPFL and MPTL reconstruction in young adults results in significant improvement in subjective knee function with minimal risks, although preinjury activity levels are not consistently restored. [4] (10.1007/s00167-018-5145-6)
• [L3] MPFL reconstruction surgery combined with LRR failed to demonstrate significantly different functional outcome scores and failure rates compared with isolated MPFL reconstruction at minimum 1-year follow up. [5] (10.1016/j.asmr.2024.100890)
• [L3] However, MPFL repair and reconstruction provide similar clinical results, return to play rates and reoperation rates. [6] (10.1177/2325967121s00618)
• [L4] Clinical scores after MPFL reconstruction provide only little insight into return to sport. [7] (10.1055/s-0039-1696647)
• [L4] Outcomes and risk profiles are similar to those of isolated MPFL reconstruction. [8] (10.1016/j.arthro.2015.11.039)
• [L4] Midterm outcomes for patients who underwent isolated MPFL reconstruction were favorable and were maintained at 5 years. [9] (10.1177/03635465241260039)
• [L3] MPFL reconstruction may provide improved midterm clinical outcomes and a decreased recurrence rate compared with MPFL repair. [10] (10.1016/j.arthro.2019.05.007)
• [L4] Surgical stabilization including MPFL reconstruction is an effective procedure for returning athletes to competitive sports with good clinical outcomes and a low rate of recurrence at 4-year follow-up. [11] (10.1007/s00167-016-4409-2)
• [L1] MPFL-R with soft-tissue graft fixation at the femoral condyles resulted in findings for subjective clinical outcome, patellar stability, and pain level similar to those associated with MPFL-R with bone fixation. [12] (10.1016/j.arthro.2018.11.051)
• [L3] MPFL/MQTFL reconstruction in skeletally immature patients with first-time patellofemoral dislocation demonstrated lower failure rates and improved functional outcomes at a minimum 2-year follow-up compared with nonoperative management. [15] (10.1016/j.arthro.2025.01.021)
• [L4] Isolated MPFL reconstruction allowed return to pre-injury sports in 91% of patients, with 67% of patients returning to the same or higher level than pre-injury. [16] (10.1007/s00167-021-06815-1)
• [L1] MPFL reconstruction in young patients can be considered an effective and safe treatment leading to clinical improvement in terms of recurrence of dislocation. [17] (10.3390/children8060434)
• [L1] Complications following primary MPFL reconstruction ranged from 0% to 32.3% of knees, primarily consisting of residual anterior knee pain. [18] (10.1016/j.arthro.2023.01.098)
• [L3] Revision surgery for MPFLR failure, including the correction of major anatomic risk factors, yielded a significant improvement in patient-reported quality-of-life outcome measures. [19] (10.1177/0363546520966354)
• [L4] Following MPFL reconstruction, patients that do not return to play exhibit poor psychological readiness with the most common reason being fear of re-injury. [20] (10.1007/s00167-021-06440-y)
• [L3] Patients undergoing MPFL reconstruction with or without correction of bony malalignment reported significant improvement over time with high return to sport rates and low recurrent dislocation rates. [21] (10.1177/2325967120s00128)
• [L3] In the majority of cases, MPFL tears do not need to be addressed at the time of multiligament reconstruction surgery. [22] (10.1177/0363546515576902)
• [L4] No anatomic risk factor independently influenced the clinical results after MPFL reconstruction significantly. [23] (10.1055/s-0039-1688917)
• [L3] Both allograft and autograft remain viable options for MPFL reconstruction with no significant differences in failure rates, patient-reported outcomes, pain, or complications. [24] (10.1177/23259671241256983)
• [L5] Both reconstruction techniques provide greater ultimate failure loads than those reported for the native MPFL in previous studies. [27] (10.1177/2325967119s00109)
• [L3] Both MPFL reconstruction and tibial tubercle transfer procedures are viable procedures allowing quick recovery, low rates of instability, and minimal risk of complication. [28] (10.1016/j.arthro.2007.03.074)
• [L4] MPFL reconstruction using allograft tissue may be performed safely in the pediatric and adolescent population with good outcomes at mid-term follow-up with few complications and low rate of recurrent instability. [29] (10.1177/2325967121s00103)
• [L3] Both allograft and autograft remain viable options in MPFL reconstruction. [30] (10.1177/2325967121s00617)
• [L5] The understanding of the complexity of the medial patellar stabilizers continues to evolve. [31] (10.1007/s00167-018-5266-y)
• [L4] The technique described offers the opportunity of an anatomical MPFL reconstruction, enabling the reconstructed ligament to have an isometric function and being effective through a greater range of motion, enabling an early functional rehabilitation, and avoiding an increase of patellofemoral pressure in higher degrees of knee flexion. [32] (10.1007/s00402-007-0300-4)
• [L4] These early and medium-term results are comparable with those of other MPFL reconstruction techniques reported in the literature. [33] (10.1177/0363546511420079)
• [L3] Thus, if a primary MPFL repair is planned, determination of the site of repair should be based on the preoperative MRI. [34] (10.1007/s00167-011-1775-7)
• [L5] [35] (10.1002/atn2.70002)
• [L3] In a cohort of patients undergoing MPFL reconstruction, the addition of an appropriately indicated TTO appears to be both safe and effective. [39] (10.1177/2325967119s00307)
• [L4] [40] (10.1002/ksa.70517)
• [L1] Patients who underwent an MPFL reconstruction in addition to a TTT had a comparatively significant improved patella congruence on quantitative CT Scan. [41] (10.1177/2325967116s00019)
• [L3] MPFL reconstruction remains as a durable surgical treatment option for patients presenting with either first-time or recurrent patellar instability with relatively low rates of recurrent instability. [42] (10.1177/2325967125s00213)
• [L3] Diagnostic arthroscopy with MPFL reconstruction may result in findings not previously appreciated on MRI. [45] (10.1177/2325967120945654)
• [L3] A preoperative jumping sign was present in almost 70% of patients with MPFL graft failure. [46] (10.1177/23259671251399799)
• [L5] Our technique is simple, anatomic, and cost-effective in incorporating the advantages of various techniques to provide a strong MPFL reconstruction with minimal complications. [47] (10.1016/j.eats.2024.103318)
• [Paper] The described MPFL reconstruction technique using a looped, double-bundle graft replicates the native shape of the MPFL while effectively limiting rotation throughout ROM and minimizing postoperative instability. [48] (10.1016/j.eats.2015.06.005)
• [L3] Patients who underwent both isolated MPFL-R and MPFL-TTO had excellent return to sport rates, with isolated MPFL-R patients reporting significantly higher rates of return to the same or higher level of sport. [50] (10.1016/j.jisako.2025.100717)
• [L5] The combined MPFL and MQTFL approach allows for a more anatomic reconstruction of the medial knee structures than previous approaches described in the literature. [51] (10.1016/j.eats.2024.103102)
• [L5] They consider the introduction of this technique will provide more insight to MPFL reconstruction. [52] (10.1016/j.eats.2021.07.032)
• [L4] [53] (10.1177/03635465231164400)
• [L3] Adolescent patients with MPFL reconstruction exhibited altered squat and jumping mechanics during the return to sport phase. [54] (10.1002/ksa.70442)
• [L2] Substantial cartilage injuries are present in 56% of patients who undergo primary isolated MPFL reconstruction, with medial patellar lesions being the most common. [55] (10.1016/j.jisako.2023.03.307)
• [L3] MPFL reconstruction in isolation or combined with MPTL reconstruction in skeletally immature patients with additional uncorrected anatomical patellofemoral abnormalities leads to acceptable clinical outcomes within a minimum of 5 years follow-up, although has a high failure rate of 24.1%. [56] (10.1016/j.jisako.2023.02.003)
• [L5] It represents an alternative to traditional anchor- or screw-based MPFL reconstruction methods. [57] (10.1002/atn2.70242)
• [L4] MPFL reconstruction using allograft tissue may be performed safely in the pediatric and adolescent population with good outcomes at midterm follow-up, few complications, and a low rate of recurrent instability. [60] (10.1016/j.arthro.2021.05.005)
• [L3] There are clinical relevant improvements in knee function and pain after MPFL reconstruction in paediatric patients. [61] (10.1007/s00167-014-3439-x)
• [L3] Substantial cartilage damage was present in 56% of patients who underwent isolated MPFL reconstruction for recurrent patellar instability, with medial patellar lesions being the most common. [62] (10.1016/j.jisako.2025.100862)
• [L5] Clinically, reconstruction of the MPFL should be performed with fixation of its anterior end to the VMO rather than to the patella. [63] (10.2106/jbjs.24.00332)
• [L5] MPFL reconstruction is an accepted method to restore static medial stabilization for patients with recurrent patellar instability who have failed nonoperative management. [66] (10.1016/j.csm.2014.03.006)
• [L5] Fixation of the MPFL graft at 60° of flexion was able to most closely restore patellofemoral contact pressure compared with the intact knee. [67] (10.1016/j.arthro.2017.09.047)
• [L5] The mean load-to-failure values for both reconstruction techniques were greater than the literature-reported values for the native MPFL. [68] (10.1177/2325967121989282)
• [L3] The lower incidence of pain complaints in the MPFL reconstruction group encourages its use as the first choice technique. [69] (10.1007/s00264-016-3119-1)
• [L5] However, in case of a patella alta (IS 1.5), a slightly more proximal femoral insertion is beneficial for the biomechanical behaviour of the reconstructed MPFL. [70] (10.1007/s00167-016-4190-2)
• [L1] Allografts may represent a feasible alternative to traditional autograft for MPFL reconstruction in selected patients with patellofemoral instability. [71] (10.1007/s00167-021-06569-w)
• [L4] Reconstruction of the MPFL produced no improvement in patellar tilt or shift in the population studied. [72] (10.1007/s00167-016-4284-x)
• [L3] MPFL reconstruction decreases recurrent dislocation compared with MPFL repair or nonoperative treatment, but it has a higher possibility of complications. [73] (10.1177/23259671211026624)
• [L2] Patients in this study treated with an MPFL-Reconstruction experienced similar complication profiles, irrespective of graft type. [74] (10.1177/2325967126s00373)
• [L2] Patients in this study treated with an MPFL reconstruction experienced similar complication profiles, irrespective of graft type. [75] (10.1177/2325967126s00257)
• [L3] MPFL reconstruction may serve as a more durable surgical treatment option with lower rates of recurrent instability and failure when compared with other patellofemoral stabilization procedures at up to 10 years after surgery. [76] (10.1177/03635465231182143)
• [L3] An increase in previously reported thresholds for when to add a bony procedure to an MPFL reconstruction can result in successful outcomes in some patients. [77] (10.1016/j.jisako.2023.03.301)
• [L4] Functional outcomes remain favorable as complication and failure profiles are improving with widespread implementation of MPFL reconstruction. [78] (10.1016/j.arthro.2014.12.029)
• [L5] [79] (10.1016/j.eats.2023.08.002)
• [L3] Patients ≥30 years at the time of MPFL reconstruction demonstrate similar subsequent dislocation risk but poorer KOOS pain subscale and Marx activity values than patients <30 years at the time of MPFL reconstruction. [80] (10.1177/23259671251324495)
• [L3] The overall risk of recurrent dislocation after MPFL-reconstruction remained high (21%) despite a rapid rise in MPFL-reconstructions from 2005 to 2013. [81] (10.1016/j.arthro.2017.08.058)
• [L3] The overall risk of recurrent dislocation after MPFL-reconstruction remained high (21%) despite a rapid rise in MPFL-reconstructions from 2005 to 2013. [82] (10.1016/j.arthro.2017.08.057)
• [L3] MPFL primary repair had significantly increased rate of complication requiring re-operation, particularly recurrent patella instability requiring revision to MPFL reconstruction. [83] (10.1177/2325967120s00189)
• [L5] [84] (10.1016/j.eats.2023.11.003)
• [Paper] This technique is technically simple and can be easily learned by surgeons familiar with adult MPFL reconstruction techniques. [113] (10.1016/j.eats.2020.03.004)
• [L4] [114] (10.1016/j.arthro.2016.01.013)
• [L5] This technique is a less invasive, straightforward, and reproducible method for repairing the torn MPFL. [117] (10.1016/j.eats.2023.10.009)
• [L3] A technique for reconstruction of the MPFL and MPTL that can be performed through a minimally invasive approach has been presented and shown to be successful in restoring stability of the patello-femoral joint in patients with traumatic and recurrent patellar instability. [118] (10.1007/s00167-011-1659-x)
• [L5] This technique provides a thoughtful and durable method for MPFL reconstruction and may be performed as an isolated procedure or in conjunction with adjunctive bony or cartilage procedures. [120] (10.1002/atn2.70087)
• [Paper] [121] (10.1016/j.eats.2017.03.005)
• [L5] Anatomically positioned reconstruction with 2-N tension fixed at 30 ° or 60 ° of knee flexion restored joint contact pressures and tracking. [123] (10.1177/0363546513509230)
• [L5] The authors describe a technique for performing final graft tensioning from the patellar side during medial patellofemoral ligament (MPFL) reconstruction. [124] (10.1016/j.eats.2022.11.017)
• [Paper] The authors describe a surgical technique for MPFL reconstruction using a suspensory fixation device for stable patellar fixation. [125] (10.1016/j.eats.2021.01.001)
• [Case_report] MPFL reconstruction using superficial quadriceps tendon autograft can be done with a minimally invasive technique without the use of specialized instrumentation and has shown excellent knee functional improvement. [126] (10.1177/2325967125s00036)
• [L4] This mini-invasive method for MPFL reconstruction is a relatively easy procedure and provides graft strength comparable to previous techniques. [127] (10.1007/s00167-008-0713-9)
• [L5] Medial quadriceps tendon femoral ligament reconstruction is the most anatomic repair, resulting in less overconstraint compared to MPFL reconstruction, though differences between techniques are small and surgical technique details remain critical. [130] (10.1016/j.arthro.2022.12.006)
• [L5] A pretension of 2 N was found to restore the knee joint closest to normal patellofemoral kinematics. [131] (10.1007/s00167-019-05668-z)
• [L3] [136] (10.1016/j.jisako.2023.03.304)
• [L4] [137] (10.1007/s00167-022-07273-z)
• [L3] Radiographic measures of tracking and alignment changed with knee motion and, in knees with instability symptoms, were most abnormal at lower flexion angles. [138] (10.1016/j.arthro.2014.04.036)
• [L4] There is substantial variability in content and timing across rehabilitation protocols following MPFL reconstruction. [139] (10.1177/2325967119855991)
• [Paper] [141] (10.1016/j.otsr.2009.09.002)
• [L4] [142] (10.1177/0363546513482085)
• [L3] Patients with MPFL reconstruction experience worse persistent patient-reported and functional deficits during the terminal phases of rehabilitation as compared to individuals with ACLR. [146] (10.1177/2325967120s00157)
• [L5] While patellar stability was similar to the intact state, kinematics were not optimal with the use of a smaller tubular graft compared to the native fan-shaped MPFL. [147] (10.1007/s00264-013-1938-x)
• [L4] Only 42.4% of US military servicemembers undergoing primary MPFL reconstruction were able to return to unrestricted impact activity after surgery. [148] (10.1177/23259671211013334)
• [L4] These findings highlight distinct anatomical phenotypes underlying dynamic patellar maltracking. [149] (10.1177/2325967126s00397)
• [Paper] Such abnormal MPFL kinematics may subsequently cause overconstraint and increased cartilage pressures of the medial patellofemoral joint. [153] (10.1002/jor.24872)
• [L5] MPFL reconstruction restores patellar kinematics and contact mechanics to the intact state when the TT is in anatomic or 5-mm lateralized positions, but fails to do so when the TT is lateralized by 10 mm or 15 mm. [154] (10.1177/0363546515597906)
• [L3] Young patients who return to sports at their pre-injury levels before 9 months after MPFLR have a higher incidence of postoperative anterior knee pain and poorer functional outcomes compared to those who delay their return. [155] (10.1002/ksa.12411)
• [L3] Patients who underwent bilateral MPFLR returned to sports at a similar rate and level compared to a unilateral comparison group. [156] (10.1007/s00167-023-07462-4)
• [L3] Only 50% of military servicemembers undergoing primary MPFL reconstruction were able to return to unrestricted impact activity. [159] (10.1016/j.arthro.2019.11.028)
• [L5] Anatomic MPFL-C resulted in a favorable graft length change range (less than 2 mm) at 0 to 90 degrees of knee flexion, which was close to the isometric graft behavior. [161] (10.1016/j.arthro.2021.10.030)
• [L5] Anatomic reconstruction of the MPFL may not fully restore patellofemoral pressure distributions compared to the native knee. [162] (10.1007/s00167-016-4005-5)
• [L3] The primary indicators of patient satisfaction at one year following MPFL reconstruction are young age, normal patellar cartilage, and good physical function at the time of surgery. [163] (10.1177/2325967125s00261)
• [L4] An accelerated rehabilitation program following isolated MPFL reconstruction is safe, effective, and yields a low risk of repeat dislocation. [165] (10.1016/j.arthro.2018.10.040)
• [L4] The VMO demonstrated clear differences in activity at return-to-sport clearance following MPFL reconstruction with a significant difference between limbs, suggesting that there may be muscle weakness following surgery and ongoing through physical therapy. [166] (10.1177/2325967126s00090)
• [L3] Clinicians should ensure that athletes are fully rehabilitated before returning to sport after MPFL-R by emphasizing functional multijoint exercises. [167] (10.1177/2325967119825854)
• [L2] There is no indication to a systematic lateral retinacular release in association with MPFL reconstruction in the treatment of RPD. [173] (10.1007/s00167-018-5294-7)
• [Paper] These findings suggest that MQTFL is a biomechanically robust alternative to MPFL reconstruction, potentially reducing fixation-related complications. [174] (10.1177/2325967126s00379)
• [L3] Patients who undergo MPFLR bilaterally are able to return to sports at a similar rate and to a similar level compared to a matched unilateral comparison group with equivalent satisfaction and functional outcome scores. [178] (10.1177/2325967123s00230)
• [L4] An accelerated rehabilitation program following isolated MPFL reconstruction is safe, effective, and yields a low risk of repeat dislocation (<2%) that is comparable to the risk reported in the existing literature. [180] (10.1016/j.arthro.2018.10.039)
• [L5] Double-bundle artificial MPFL reconstruction using a femoral suture-sliding anchor and staged patellar fixation offers a reproducible method to adjust graft tension, reduce the risk of over-constraint, and better restore the anatomical configuration of the native MPFL. [181] (10.1002/atn2.70004)
• [Paper] Successful execution of this procedure provides a strong MPFL construct that allows patients to undergo early aggressive rehabilitation and return to activities. [182] (10.1016/j.eats.2020.11.018)
• [L5] The patellar contact pressures after the dynamic MPFLr were like those of the native knee, whereas a static reconstruction resulted in greater pressures, potentially increasing the risk of patellofemoral osteoarthritis in the long term. [183] (10.3390/jcm8122093)
• [L4] The altered function of the patellar tendon in anterior cruciate ligament deficiency resulted in an altered patellar tracking and patellofemoral cartilage contact. [184] (10.1177/0363546508314404)
• [L3] Joint hypermobility is not a contraindication to MPFL reconstruction, although caution is recommended in managing the expectations of patients with hypermobility before consideration of surgery. [186] (10.1302/0301-620x.94b12.29562)
• [L4] IMGG with plates or screws in the setting of combined MPFL reconstruction improves genu valgum. [188] (10.1177/03635465231222934)
• [L5] Three methods of reconstruction were stronger than the native MPFL, with the strongest being interference screw patella suspensory cortical fixation femur. [192] (10.1016/j.arthro.2014.04.035)
• [L5] MPFL grafts tend to carry minimal load beyond 30 of knee flexion during functional activities. [193] (10.1016/j.arthro.2019.11.026)
• [L4] Medial patellar instability following lateral retinacular release occurs during the unloading phase of gait when passive structures guide the patella, weakening the argument that muscle imbalance is the primary cause. [194] (10.1007/s001670050034)
• [L5] MPFL reconstruction with 3 transosseous sutures provided a higher load to failure than did the commonly used fixation method involving suture anchors. [195] (10.1177/23259671211041404)
• [Paper] MPFL reconstruction with a free semitendinosus graft using a suspensory adjustable-loop cortical button and interference screw fixation on the femoral side, as well as knotless suture anchor fixation in 2 bone sockets on the patellar side, is a reproducible technique for patellar stabilization in patients with acute or recurrent instability. [196] (10.1016/j.eats.2013.10.001)
• [L5] Both fixation techniques provided sufficient primary stability, superior to previously reported native MPFL tensile strengths. [197] (10.1007/s00167-022-07120-1)
• [L4] [201] (10.1177/0363546513477828)
• [L4] The MPFC fibers demonstrated increased length changes in knees when a greater number of morphological risk factors for patellar instability were present, which worsened in the setting of nonanatomic configurations. [203] (10.1177/03635465231165296)
• [L3] PPR has demonstrated durable results, with a lower overall complication rate, much of which is caused by the MPFL reconstruction having unique complications due to fixation methods. [204] (10.2106/jbjs.rvw.24.00112)
• [L1] There was insufficient evidence to conclude that the addition of MPFL reconstruction to TTT results in fewer redislocations or reoperations. [205] (10.1177/0363546516666352)
• [L3] Patients who underwent MPFLR with anteromedializing TTO demonstrated similar rates of return to sport and psychological readiness compared to an isolated MPFLR matched comparison group, though iMPFLRs returned more quickly. [206] (10.1002/ksa.12051)
• [L5] There was no consensus on the use of anchors in MPFL reconstruction, the order of fixation of the graft, indications for trochleoplasty, postoperative immobilization, or early return to sport in paediatric patients. [208] (10.1302/0301-620x.105b12.bjj-2023-0110.r1)
• [L4] MPFL reconstruction techniques with patellar bone sockets showed a larger range of complication rates than cortical fixation techniques, although overall, complications remained uncommon. [209] (10.1016/j.arthro.2018.10.150)
• [L3] MPFL reconstruction with both semitendinosus and pedicled quadriceps tendon grafts yields successful results in well-selected patient groups. [211] (10.1002/ksa.12619)
• [L4] [212] (10.1016/j.otsr.2015.06.030)
• [L2] Measurement of the femoral tunnel position on postoperative lateral radiographs is not an accurate or reliable method for evaluating tunnel position after MPFL reconstruction due to exposure, contrast, and malrotation of the radiograph from a true-lateral image. [214] (10.1007/s00167-019-05378-6)
• [L4] These results suggest that pediatric opioid prescribing practices after MPFLR have become more conservative, reflecting ongoing efforts to reduce opioid use in surgical care while maintaining effective pain management. [215] (10.1177/2325967126s00134)
• [L3] Individual psychological characteristics and personality structures have a significant influence on the functional outcome and the psychological readiness to return to sport after MPFL reconstruction. [216] (10.1016/j.jisako.2025.100735)
• [L5] MPFL-R with a nonresorbable suture tape can normalize patellar maltracking in fresh-frozen human knee joint specimens in earlier degrees of knee joint flexion independent of patella-side fixation technique. [219] (10.1007/s00167-022-07256-0)
• [L3] There were no significant differences in return to activity, pain score changes, or incidences of failure between patients undergoing MPFLR with allograft versus autograft. [221] (10.1177/2325967118774272)
• [L3] [226] (10.1016/j.arthro.2017.08.054)
• [L4] MPFL reconstruction, alone or in combination, seems to be an effective treatment for recurrent patellar dislocations after a failed previous surgery, leading to significant increases in stability and functionality as well as a reduction in pain. [227] (10.1177/0363546513498572)
• [L4] MPFL reconstruction provides a consistent reduction in patellar height measurements. [228] (10.1177/2325967117751659)
• [L5] [230] (10.2106/jbjs.22.00756)
• [L5] [231] (10.1007/s00167-012-1968-8)
• [L4] Following MPFL reconstruction, 42% of patients return to sport at lower activity levels compared to pre-injury level, especially in older patients and patients who undergo concomitant tibial tubercle osteotomy. [232] (10.1016/j.arthro.2019.11.027)
• [L5] [238] (10.1016/j.arthro.2023.01.006)
• [L5] [239] (10.1177/0363546506296415)
• [L3] [240] (10.1016/j.arthro.2023.07.006)
• [L5] [241] (10.1016/j.eats.2025.103804)
• [L2] [242] (10.1186/s13018-021-02513-3)
• [L2] [243] (10.1016/j.otsr.2018.10.002)
• [L4] The clinical success of this operation depends on restoration of the anatomical origin of the MPFL and careful patient selection. [245] (10.1177/0363546510376230)
• [L5] [249] (10.1186/s13018-017-0530-2)
• [L5] [250] (10.1016/j.eats.2022.03.033)
• [L4] [252] (10.1007/s00167-010-1235-9)
• [L4] [253] (10.1007/s00167-021-06603-x)
• [L3] Matched patients undergoing MPFLR with TTO compared with isolated MPFLR demonstrate no statistically significant difference in patient-reported outcomes, levels of pain, and satisfaction postoperatively. [254] (10.1016/j.jisako.2021.10.004)
• [L3] Combined MPFLRTTO increased the overall complication rate but had a lower 2-year rate of recurrent instability requiring revision than MPFLR alone. [257] (10.1016/j.asmr.2024.100994)
• [L4] Tailored revision surgery for failed MPFL-R significantly improves the patient-reported disease-specific quality of life. [259] (10.1007/s00167-021-06734-1)
• [L4] There was a low rate of recurrent instability following MPFLR with allograft, with excellent patient reported outcomes, and a low complication rate. [260] (10.1177/2325967121s00296)
• [L3] This study demonstrates that primary MPFL+TTO versus revision MPFL+TTO have comparable objective and subjective outcomes at short term follow-up. [261] (10.1016/j.arthro.2023.01.081)
• [L3] This study demonstrates that primary MPFL+TTO versus revision MPFL+TTO have comparable objective and subjective outcomes at short term follow-up. [262] (10.1177/2325967121s00557)
• [L4] The surgical procedure of operative repair (reattachment) of the MPFL to its femoral attachment had a significantly high rate of failure in this patient group of chronic (repeat) lateral patellar dislocators. [265] (10.1007/s00167-011-1516-y)
• [L4] Multiple anatomic risk factors and femoral tunnel malposition are commonly observed in patients with reinstability after primary MPFL reconstruction. [266] (10.1177/2325967120926178)
• [L3] Of 428 patients undergoing primary MPFLR, 22.9% underwent concomitant LR or LL. [267] (10.1177/23259671251331038)
• [L4] Isolated MPFL reconstruction using a high-strength suture tape construct resulted in durable patellar stability and high patient-reported success at a minimum 5-year follow-up. [268] (10.1002/ksa.70466)
• [L3] Approximately 23% of primary MPFLR patients underwent LR/LL. [271] (10.1177/2325967125s00223)
• [L1] This systematic review and meta-analysis found that recurrent patellofemoral instability rates after MPFL reconstruction techniques are in the range of instability rates after other soft tissue realignment techniques. [272] (10.1007/s00167-019-05656-3)
• [L3] Although revision MPFL-R establishes acceptable patellar stability, the subjective outcomes after revision MPFL-R do not improve significantly and are poorer than after primary MPFL-R. [274] (10.1007/s00167-017-4477-y)
• [L4] The meta-analysis of 17 case series shows that MPFL reconstruction for recurrent patellar dislocation results in a significant improvement in Kujala scores, a low redislocation rate, and acceptable complication rate. [275] (10.1177/2325967114544021)
• [L3] The addition of TTO to MPFLR reduced revision surgical rates for instability from 11.1 to 6.6% but this difference was not statistically significant. [276] (10.1177/2325967121s00793)

See Also

• Patellofemoral instability
• Anatomy
• ACL reconstruction

References

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[56] Medial patellofemoral ligament reconstruction in skeletally immature patients without correction of bony risk factors leads to acceptable outcomes but higher failure rates. Journal of ISAKOS. 2023. DOI: 10.1016/j.jisako.2023.02.003

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[155] Returning to pre‐injury level of sports before 9 months after medial patellofemoral ligament reconstruction increases the incidence of anterior knee pain in young patients. Knee Surgery, Sports Traumatology, Arthroscopy. 2024. DOI: 10.1002/ksa.12411

[156] Patients who undergo bilateral medial patellofemoral ligament reconstruction return to sport at a similar rate as those that undergo unilateral reconstruction. Knee Surgery, Sports Traumatology, Arthroscopy. 2023. DOI: 10.1007/s00167-023-07462-4

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[166] Differential Quadriceps Muscle Dysfunction Preoperatively and at Return to Sport Following Medial Patellofemoral Ligament Reconstruction. Orthopaedic Journal of Sports Medicine. 2026. DOI: 10.1177/2325967126s00090

[167] Biomechanical and Functional Outcomes After Medial Patellofemoral Ligament Reconstruction: A Pilot Study. Orthopaedic Journal of Sports Medicine. 2019. DOI: 10.1177/2325967119825854

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[183] Evaluation of Patellar Contact Pressure Changes after Static versus Dynamic Medial Patellofemoral Ligament Reconstructions Using a Finite Element Model. Journal of Clinical Medicine. 2019. DOI: 10.3390/jcm8122093

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[205] Medial Patellofemoral Ligament Reconstruction Combined With Distal Realignment for Recurrent Dislocations of the Patella: 5-Year Results of a Randomized Controlled Trial. The American Journal of Sports Medicine. 2016. DOI: 10.1177/0363546516666352

[206] Patients who undergo tibial tubercle anteromedialization with medial patellofemoral ligament reconstruction demonstrate similar rates of return to sport compared to isolated MPFL reconstruction. Knee Surgery, Sports Traumatology, Arthroscopy. 2024. DOI: 10.1002/ksa.12051

[208] A modified Delphi consensus statement on patellar instability: part II. The Bone & Joint Journal. 2023. DOI: 10.1302/0301-620x.105b12.bjj-2023-0110.r1

[209] Systematic Review of Medial Patellofemoral Ligament Reconstruction Techniques: Comparison of Patellar Bone Socket and Cortical Surface Fixation Techniques. Arthroscopy. 2019. DOI: 10.1016/j.arthro.2018.10.150

[211] Comparison of double bundle semitendinosus technique and pedicled quadriceps technique in patellar instability. Knee Surgery, Sports Traumatology, Arthroscopy. 2025. DOI: 10.1002/ksa.12619

[212] Surgical reconstruction of the medial patellofemoral ligament. Orthopaedics & Traumatology: Surgery & Research. 2016. DOI: 10.1016/j.otsr.2015.06.030

[214] Radiographic images are inapplicable for a precise evaluation of the femoral tunnel position following MPFL reconstruction. Knee Surgery, Sports Traumatology, Arthroscopy. 2019. DOI: 10.1007/s00167-019-05378-6

[215] Opioid Prescription Patterns Following Medial Patellofemoral Ligament Reconstruction in Pediatric Patients: A 13-Year National Database Analysis. Orthopaedic Journal of Sports Medicine. 2026. DOI: 10.1177/2325967126s00134

[216] Patient Specific Psychological Characteristics and Personality Structure Affect Postoperative Outcomes and Return to Sport Following Isolated Medial Patellofemoral Ligament Reconstruction. Journal of ISAKOS. 2025. DOI: 10.1016/j.jisako.2025.100735

[219] Reconstruction of the medial patellofemoral ligament with nonresorbable suture tape normalizes patellar maltracking independent of patella‐side fixation technique. Knee Surgery, Sports Traumatology, Arthroscopy. 2022. DOI: 10.1007/s00167-022-07256-0

[221] Adolescent Medial Patellofemoral Ligament Reconstruction: A Comparison of the Use of Autograft Versus Allograft Hamstring. Orthopaedic Journal of Sports Medicine. 2018. DOI: 10.1177/2325967118774272

[226] Paper #65: Allograft Versus Autograft for Medial Patellofemoral Ligament Reconstruction. Arthroscopy. 2017. DOI: 10.1016/j.arthro.2017.08.054

[227] Isolated and Combined Medial Patellofemoral Ligament Reconstruction in Revision Surgery for Patellofemoral Instability. The American Journal of Sports Medicine. 2013. DOI: 10.1177/0363546513498572

[228] Medial Patellofemoral Ligament Reconstruction Reduces Radiographic Measures of Patella Alta in Adults. Orthopaedic Journal of Sports Medicine. 2018. DOI: 10.1177/2325967117751659

[230] Lateral Patellar Instability. Journal of Bone and Joint Surgery. 2023. DOI: 10.2106/jbjs.22.00756

[231] Arthroscopic extraarticular reconstruction of the medial patellofemoral ligament with gracilis tendon autograft ‐ surgical technique. Knee Surgery, Sports Traumatology, Arthroscopy. 2012. DOI: 10.1007/s00167-012-1968-8

[232] Return to Sport Following Medial Patellofemoral Ligament Reconstruction. Arthroscopy. 2019. DOI: 10.1016/j.arthro.2019.11.027

[238] Medial Patellofemoral Reconstruction Techniques for Patellar Instability. Arthroscopy. 2023. DOI: 10.1016/j.arthro.2023.01.006

[239] Radiographic Landmarks for Femoral Tunnel Placement in Medial Patellofemoral Ligament Reconstruction. The American Journal of Sports Medicine. 2007. DOI: 10.1177/0363546506296415

[240] Medial Patellofemoral Ligament Reconstruction Using Pedicled Quadriceps Tendon Autograft Yields Similar Clinical and Patient‐Reported Outcomes but Less Donor‐Site Morbidity Compared With Gracilis Tendon Autograft. Arthroscopy. 2023. DOI: 10.1016/j.arthro.2023.07.006

[241] Surgical Techniques to Address Patellofemoral Instability: An Individualized Approach. Arthroscopy Techniques. 2025. DOI: 10.1016/j.eats.2025.103804

[242] Conservative versus tailored surgical treatment in patients with first time lateral patella dislocation: a randomized-controlled trial. Journal of Orthopaedic Surgery and Research. 2021. DOI: 10.1186/s13018-021-02513-3

[243] Axial patellar engagement index and patellar tilt after medial patello-femoral ligament reconstruction in children and adolescents. Orthopaedics & Traumatology: Surgery & Research. 2019. DOI: 10.1016/j.otsr.2018.10.002

[245] Medial Patellofemoral Ligament Repair for Recurrent Patellar Dislocation. The American Journal of Sports Medicine. 2010. DOI: 10.1177/0363546510376230

[249] Biomechanical comparison of single- and double-bundle medial patellofemoral ligament reconstruction. Journal of Orthopaedic Surgery and Research. 2017. DOI: 10.1186/s13018-017-0530-2

[250] A Simple Instrument for Intraoperative Fluoroscopic Localization of Anatomic Insertions in Medial Patellofemoral Ligament Reconstruction. Arthroscopy Techniques. 2022. DOI: 10.1016/j.eats.2022.03.033

[252] Graft length change and radiographic assessment of femoral drill hole position for medial patellofemoral ligament reconstruction. Knee Surgery, Sports Traumatology, Arthroscopy. 2010. DOI: 10.1007/s00167-010-1235-9

[253] Femoral tunnel malposition is the most common indication for revision medial patellofemoral ligament reconstruction with promising early outcomes following revision reconstruction: a systematic review. Knee Surgery, Sports Traumatology, Arthroscopy. 2021. DOI: 10.1007/s00167-021-06603-x

[254] Adding a tibial tubercle osteotomy with anteromedialisation to medial patellofemoral ligament reconstruction does not impact patient-reported outcomes in the treatment of patellar instability. Journal of ISAKOS. 2022. DOI: 10.1016/j.jisako.2021.10.004

[257] Combined Medial Patellofemoral Ligament Reconstruction and Tibial Tubercle Osteotomy Has a Lower Risk of Recurrent Instability Requiring Revision Stabilization at 2 Years Than Either Procedure Alone. Arthroscopy, Sports Medicine, and Rehabilitation. 2024. DOI: 10.1016/j.asmr.2024.100994

[259] Revision surgery for failed medial patellofemoral ligament reconstruction results in better disease‐specific outcome scores when performed for recurrent instability than for patellofemoral pain or limited range of motion. Knee Surgery, Sports Traumatology, Arthroscopy. 2021. DOI: 10.1007/s00167-021-06734-1

[260] Outcomes following Medial Patellofemoral Ligament Reconstruction with Allograft (177). Orthopaedic Journal of Sports Medicine. 2021. DOI: 10.1177/2325967121s00296

[261] Podium Presentation Title: Outcomes for Medial Patellofemoral Ligament Reconstruction with Concomitant Tibial Tubercle Osteotomy for Failed Patellar Stabilization versus Primary Medial Patellofemoral Ligament Reconstruction with Concomitant Tibial Tubercle Osteotomy. Arthroscopy. 2023. DOI: 10.1016/j.arthro.2023.01.081

[262] Paper 19: Outcomes for Primary versus Revision Medial Patellofemoral Ligament Reconstruction with Concomitant Tibial Tubercle Osteotomy. Orthopaedic Journal of Sports Medicine. 2022. DOI: 10.1177/2325967121s00557

[265] Clinical outcomes of medial patellofemoral ligament repair in recurrent (chronic) lateral patella dislocations. Knee Surgery, Sports Traumatology, Arthroscopy. 2011. DOI: 10.1007/s00167-011-1516-y

[266] Failure Analysis in Patients With Patellar Redislocation After Primary Isolated Medial Patellofemoral Ligament Reconstruction. Orthopaedic Journal of Sports Medicine. 2020. DOI: 10.1177/2325967120926178

[267] Factors Associated With the Decision to Perform a Lateral Retinacular Release or Lengthening During Medial Patellofemoral Ligament Reconstruction in the JUPITER Cohort. Orthopaedic Journal of Sports Medicine. 2026. DOI: 10.1177/23259671251331038

[268] Durable patellar stability and high patient‐reported success at minimum 5‐year follow‐up after isolated suture tape MPFL reconstruction. Knee Surgery, Sports Traumatology, Arthroscopy. 2026. DOI: 10.1002/ksa.70466

[271] Poster 126: Factors Associated with the Decision to Perform a Lateral Retinacular Release or Lengthening During Medial Patellofemoral Ligament Reconstruction in the JUPITER Cohort. Orthopaedic Journal of Sports Medicine. 2025. DOI: 10.1177/2325967125s00223

[272] Recurrent patellofemoral instability rates after MPFL reconstruction techniques are in the range of instability rates after other soft tissue realignment techniques. Knee Surgery, Sports Traumatology, Arthroscopy. 2019. DOI: 10.1007/s00167-019-05656-3

[274] Clinical outcomes after revision surgery for medial patellofemoral ligament reconstruction. Knee Surgery, Sports Traumatology, Arthroscopy. 2017. DOI: 10.1007/s00167-017-4477-y

[275] Medial Patellofemoral Ligament Reconstruction for Patellar Dislocation. Orthopaedic Journal of Sports Medicine. 2014. DOI: 10.1177/2325967114544021

[276] Poster 232: Performing a Concomitant Tibial Tubercle Osteotomy During Primary Medial Patellofemoral Ligament Reconstruction Does Not Lead to Increased Post-Operative Complication Rates. Orthopaedic Journal of Sports Medicine. 2022. DOI: 10.1177/2325967121s00793